US Guided Procedures

Question 1

You are evaluating a patient that had a balloon angioplasty on the proximal superficial femoral artery 3 years ago. The acceleration time in the common femoral artery is 230ms. This finding is most suggestive of:
A. recurrence of stenosis in the proximal superficial artery
B. normal arterial flow
C. obstruction in the distal superficial femoral artery
D. iliac artery stenosis

Answer 1

D
Increased acceleration time indicates a proximal stenosis. There is probably an iliac artery stenosis and the arteries proximal to the CFA should be evaluated.

Question 2

Which of the following is true regarding the initial post-op examination of a transjugular intrahepatic portosystemic shunt placement?
A. marked ascites is a common finding for the initial post-op exam on a TIPS patient
B. CTA is most commonly performed for the initial evaluation of the TIPS procedure
C. it should be performed within 30 days following the procedure
D. it helps to establish baseline velocities for upcoming follow up exams

Answer 2

D
When performing serial evaluations of a TIPS, it is important to establish a baseline for the patient very soon after the shunt placement. The initial evaluation should be performed with Doppler ultrasound within 24 hrs of shunt placement.

Question 3

Which of the following procedures allows patients to continue their normal course of anticoagulant therapy before and after the procedure?
A. ascending venography
B. carotid endarterectomy
C. compression therapy of pseudoaneurysm
D. percutaneous transluminal angioplasty

Answer 3

A
Venography is performed using a venous puncture. Surgical procedures and invasive procedures that require an arterial puncture have an increased risk of hemorrhage when the blood is thinned by anticoagulants. Patients having these procedures must discontinue their anticoagulant therapy before the procedure. Thinned blood will also inhibit the clot formation in a pseudoaneurysm.

Question 4

Which of the following statements correctly describes an endovenous laser ablation of the GSV?
A. the procedure is much more easily performed if the patient already has DVT
B. the procedure is considered a success if thrombus fills the GSV from the ankle to the SFJ
C. the physician injects a halo of anesthesia medicine around the GSV
D. intravascular ultrasound is performed after the procedure to confirm success

Answer 4

C
Physician injects anesthesia around the vein being treated = tumescent anesthesia. A 1cm ring of anesthesia medicine should surround the vein for the appropriate level of patient comfort during the procedure. The catheter is inserted in the distal vein and advanced to the most proximal point that will be treated. The laser is turned on and the physician slowly retracts the catheter until it reaches the insertion point. A follow up ultrasound exam is performed in a week or two to evaluate the success of the procedure. The deep system should be evaluated for thrombus, the treated vein should be evaluated for diameter measurements and with color flow. The distance between the SFJ and most proximal point of closure of the GSV should be measured. If thrombus extends into the deep system, the GSV must me ligated. DVT is a contraindication for the procedure.

Question 5

Which of the following is a contraindication of US guided compression therapy for a pseudoaneurysm at the groin?
A. a pseudoaneurysm that measures 3.2cm in diameter
B. a pseudoaneurysm that has been present for more than 72hrs
C. infection at the puncture site
D. patient that stopped taking Coumadin 3 days ago

Answer 5

C
Contraindications for US guided compression therapy for a pseudoaneurysm:
Patient unable to tolerate the procedure due to pain
Infection at the puncture site and surrounding tissues
Diameter >4cm
Stalk diameter > 5mm
Present for more than 1 month
Patients on anticoagulant therapy (must be stopped before compression).

Question 6

Which of the following is a treatment for a pseudoaneurysm?
A. thrombin injection
B. compression stockings
C. Coumadin
D. IV Heparin

Answer 6

A
A Thrombin injection is used to treat pseudoaneurysms with large stalks. Ultrasound guidance is used to make the injection that promotes thrombosis of the stalk and body of the pseudoaneurysm. Coumadin is a blood thinner that would decrease the ability of clot formation in the pseudoaneurysm. IV Heparin is used to treat DVT.

Question 7

A physician orders a vein mapping of the left upper extremity for potential arterial bypass harvesting but does not indicate when vessel he plans to use. Which vein should you evaluate because it is the most commonly used for bypass?
A. antecubital vein
B. radial vein
C. brachial vein
D. cephalic vein

Answer 7

D

The cephalic vein is most commonly harvested for use as a bypass.

Question 8

Which of the following measurements should be obtained to evaluate the success of a percutaneous angioplasty performed on the left superficial femoral artery?
A. femoral artery diameters proximal to the treated area, the treated area and distal to the treated area
B. peak systolic velocity and velocity ratio
C. acceleration time and pulsatility index
D. more than one of the above

Answer 8

D

You are assisting with a mesenteric stent placement procedure for a patient with 75% SMA stenosis.

Question 9

You are assisting with a mesenteric stent placement procedure for a patient with 75% SMA stenosis. The physician is using intraoperative US to intermittently monitor the flow in the SMA while performing angioplasty on the vessel. He asks you to watch the tracings and let him known when the flow improves. What are you watching for?
A. change from monophasic to peaked triphasic
B. increased resistance and decreased diastolic flow
C. decreased resistance and increased diastolic flow
D. change from peaked triphasic to monophasic

Answer 9

B
Normal pre-prandial flow in the SMA is high resistance with low levels of diastolic flow (monophasic). 75% SMA stenosis would cause a low resistance waveform with increased systolic and diastolic velocities. The resistance would increase in the mesenteric vascular beds as normal flow levels resume after angioplasty. Diastolic flow levels would reduce because the mesentery is now receiving enough blood during systole. Peak systolic and end diastolic velocities are reduced.

Question 10

A patient presents for a follow up for the TIPS located between the right portal vein and right hepatic vein. The chart indicates an abnormal bruit and stenosis is suspected. Where should you look first for the stenosis because it is the most common site of stenosis in a TIPS?
A. biliary anastomosis
B. hepatic artery anastomosis
C. portal vein anastomosis
D. hepatic vein anastomosis

Answer 10

D

The hepatic vein anastomosis is the most common site of stenosis in a TIPS.

Question 11

In most cases, a peripherally inserted central catheter (PICC) line is inserted in the basilic vein exam and advanced until the tip reaches:
A. brachiocephalic vein
B. proximal subclavian vein
C. axillary vein
D. atriocaval junction

Answer 11

D
The terminal tip of the venous catheter is positioned in a central vein, most commonly the distal 1/3 of the SVC (atriocaval junction). High blood flow volume in this location allows for infusates to be rapidly distributed.

Question 12

What is an absolute contraindication for sclerotherapy?
A. vein location above the inguinal ligament
B. polycythemia vera
C. patient allergy to injectate
D. vein location immediately over a bony prominence

Answer 12

C
Absolute contraindications are situations which make a particular treatment or procedure absolutely inadvisable. The risk of complications cause by the patient allergy to the injected substance (sclerosant) far exceed the benefits of the procedure. The patient will be treated using other methods.

Question 13

All of the following correctly describe proper behavior related to a sterile field, except:
A. when in doubt about sterility, discard the potentially contaminated item and begin again
B. sterile gloves must be used to open the procedure tray
C. sterile individuals must pass each other back to back when moving around the procedure room
D. hands and elbows must be kept above the level of the table

Answer 13

B
Steile packages can be opened with non-sterile gloves but if any items inside the tray will be touched, sterile gloves must be used. Sterile gloves must be used to remove items for the tray to prepare them (lidocaine, needle, syringe, biopsy instrument).

Question 14

When preparing the sterile tray for an invasive procedure, the cover on the tray should be opened:
A. by pulling the far cover of the wrapper toward you
B. by the radiologist
C. while wearing sterile gloves
D. no more than 2 hours before the procedure begins

Answer 14

A
The Sonographer should prepare the supplies for an ultrasound guided procedure. The tray should not be opened until just before the procedure begins. The cover can be opened without wearing gloves but should be pulled toward you to expose the products facing away from you. This prevents your arm from hovering over the supplies to prevent any “debris from your person from falling into the tray. Sterile gloves must be used to remove items for the tray to prepare them (lidocaine, needle and syringe).

Question 15

Which of the following is a contraindication for harvesting of the great saphenous vein?
A. chronic obstruction of the femoral vein
B. chronic obstruction of the peroneal veins
C. Baker’s cyst in the ipsilateral popliteal fossa
D. valvular incompetence in the great saphenous vein

Answer 15

A
IT IS VERY IMPORTANT to evaluate the venous outflow system of a patient prior to removal or closure of the saphenous vein. If the deep system is obstructed and the superficial system is the main outflow for the leg, the saphenous vein cannot be removed/closed.

Question 16

Which of the following describes the sonographic appearance of a TIPS?
A. shunts are not easily evaluated Sonographically and CTA is the preferred method for evaluation
B. strongly reflective curved structure connecting the right portal vein and right hepatic vein
C. requires color Doppler evaluation for visualization of the graft within the liver
D. anaechoic tube, without distinctive wall reflection, that connects the right hepatic vein to the right portal vein

Answer 16

B
The shunt is constructed of metallic substances with increased reflectivity in order to allow for better sonographic visualization. The sonographic appearance of a TIPS is a strongly reflective curved structure connecting the right portal vein and right hepatic vein.

Question 17

Which of the following is not an expected finding with an AV fistula caused by an interventional procedure?
A. direct connection between a single artery and vein
B. low resistance arterial inflow
C. dilated venous collaterals adjacent to the fistula
D. pulsatile venous outflow

Answer 17

C
An AVM is a congenital malformation with multiple connections between the arterioles and venules without a capillary bed in between. Venous collaterals will develop and dilate over time. An AVF is a direct connection of an artery or vein caused by trauma or interventional procedure. Due to the acute formation of the connection, there are no collaterals present. The arterial inflow and venous outflow will demonstrate the same hemodynamic characteristics in an AVM and AVF, increased arterial flow volume, low resistance arterial inflow and pulsatile, turbulent venous outflow.

Question 18

Which of the following is NOT a part of the information required on an informed consent form for an interventional vascular procedure?
A. possible complications that the patient may experience
B. signature line to indicate patient consent
C. description of the procedure
D. percentage of patients that have experienced complications after the same procedure at the facility

Answer 18

D
The informed consent must include a description of the procedure and list the possible complications that the patient may experience. The patient must be of sound mind when giving consent by signature.

Question 19

Which of the following is true regarding compression techniques used to treat a pseudoaneurysm of the femoral artery in the groin?
A. compression should be performed in 30 second intervals with color Doppler evaluation in between compressions
B. pressure equivalent to 100mmHg should be performed in three ten minute intervals and if this does not close the stalk, alternative treatment must be considered
C. blood pressure evaluation cannot be performed anywhere on the legs until the stalk to the pseudoaneurysm is closed
D. thrombin injection is more effective than compression techniques in pseudoaneurysms with large diameter stalks

Answer 19

D
Thrombin injection is more effective than compression techniques in pseudoaneurysms with large diameter stalks. Ankle pressure should be monitored during compression techniques to avoid changes in distal flow from extrinsic compression. Compression should be performed in 10 - one minute intervals with color Doppler evaluation in between compression.

Question 20

Which of the following techniques cannot be used to monitor distal flow in the leg while compression therapy for a pseudoaneurysm is performed?
A. Doppler evaluation of the PTA or DPA
B. pressure monitor on the great toe
C. PPG senor on the great toe
D. PPG sensor on the ankle

Answer 20

D
When PPG is used to evaluate arterial flow, the sensors are placed on the great toes. When PPG is used to evaluate venous reflux, the sensor is placed on the lower calf near the ankle. It is contraindicated to obtain an ankle pressure in a patient with an acute pseudoaneurysm. A toe monitor can be used because the inflation of the cuff has little to no effect on pressure in the femoral artery.

Question 21

Which of the following is an advantage of intraoperative vascular ultrasound compared to intraoperative angiography?
A. provides real time flow evaluation
B. can be performed during the surgical procedure
C. technique does not require vessel puncture to obtain flow information
D. can assess flow in all branches of the intracerebral vessels

Answer 21

C
Angiography is an invasive procedure that requires a vessel puncture to administer contrast. Intraoperative IS is performed by placing the transducer on the artery, no punture required to obtain flow information. Both ultrasound and angiography can provide real time blood flow information because the contrast flow is evaluated live with fluoroscopy on angiography. Ultrasound does not evaluate all branches of the intracerebral vessels while angiography can visualize all patent branches in the FOV. Both techniques can be performed during the surgery.

Question 22

Which of the following statements is false regarding intraoperative duplex evaluation during a carotid endarterectomy?
A. the technique is used to assess the immediate flow changes within the vessel undergoing the endarterectomy
B. the probe is placed in direct contact on the vessel that is being evaluated so the sterile technique is required
C. due to the increased attenuation of sound caused by air in the extracranial vessels, the lowest probe frequency available is preferred for the exam
D. the highest probe frequency available is preferred for intraoperative duplex evaluation

Answer 22

C
The technique is used to assess the immediate flow changes within the vessel undergoing the endarterectomy. The highest probe frequency available is preferred for intraoperative duplex evaluation. The probe is placed in direct contact on the vessel that is being evaluated so the sterile technique is required. The vessel should not contain air because it would become a cerebral embolism.

Question 23

Which of the following requires the use of sterile technique?
A. vein mapping
B. laser ablation for telangiectasia
C. sclerotherapy
D. radiofrequency venous ablation

Answer 23

D
Radiofrequency ablation requires the sterile technique because the procedure requires the puncture of the saphenous vein to insert a catheter into the length of the vein. The other choices do not require the sterile technique. Telangiectasia refers to dilated very small superficial veins that are treated with external application of laser treatment. Sclerotherapy refer to the injection of a solution into spider veins to cause them to atrophy and requires aseptic technique. Vein mapping is performed with ultrasound.

Question 24

Which of the following is a contraindication for endovenous laser ablation of the great saphenous vein?
A. valvular incompetence in the great saphenous vein
B. Baker’s cyst in the ipsilateral popliteal fossa
C. chronic obstruction of the peroneal veins
D. chronic obstruction of the femoral vein

Answer 24

D

Question 25

In most patient with a central venous catheter the tip of the catheter is positioned in the:
A. internal jugular vein
B. proximal subclavian vein
C. distal subclavian vein
D. distal 1/3 of the superior vena cava

Answer 25

D
The terminal tip of the venous catheter is positioned in a central vein, most commonly the distal 1/3 of the SVC (atriocaval junction). High blood flow volume in this location allows infusates to be rapidly distributed.

Question 26

A common complication of cardiac catheterization is the formation of:
A. pseudoaneurysm
B. arterial dissection
C. fusiform aneurysm
D. DVT

Answer 26

A
During the catheterization the superficial femoral artery is punctured by the catheter as it enters the arterial system. Once the catheter is removed, there is a risk that blood will escape the artery into the surrounding tissues to form a pseudoaneurysm.

Question 27

At __________ post-injection, ___________ should be performed to determine the success of a Thrombin injection for pseudoaneurysm treatment.
A. 20 minutes, color Doppler and ABI evaluation
B. 5 minutes, PPG and ABI evaluation
C. 1 hour, color Doppler evaluation
D. 24-48 hours, color Doppler and ABI evaluation

Answer 27

A
At 20 minutes post-injection, color Doppler and ABI evaluation should be performed to determine the success of a Thrombin injection for pseudoaneurysm treatment. The PSA should be filled with echogenic thrombus and no color flow should be present within it. ABI assessment is performed before and after the procedure to confirm the arterial circulation was unaffected. There should be no change in the ABI from the baseline assessment.

Question 28

Prior to any invasive procedure, the patient should be educated about the procedure, expected outcomes and any possible complications. The patient will be required to sign a document stating their understanding of these topics in order to proceed with the procedure. This form is called:
A. health incurance waiver
B. informed consent form
C. ligation waiver
D. patient acceptance form

Answer 28

B

Question 29

Which of the following indicates a balloon angioplasty of an 80% stenosis of the superficial femoral artery was a success?
A. increased damping in the inflow artery
B. velocity ratio greater than 2.0
C. decrease in the pulsatility index distal to the treated segment
D. an increase in the ABI of at least 0.15

Answer 29

D
Resolution of patient symptoms, an ABI increase >0.15 and <50% diameter stenosis on duplex ultrasound indicate a successful PTLA. Angioplasty failure = damped, low-velocity waveforms in the distal arterial tree, no change in the post-procedure ABI.

Question 30

Which of the following is a responsibility of a Sonographer when assisting with a radiofrequency ablation of he great saphenous vein?
A. to advance the ultrasound catheter during the procedure
B. to perform initial puncture for the catheter prior to the vascular surgeon entering the room
C. to operate the ultrasound machine controls and/or the probe, as directed by the physician
D. to send the ultrasound catheter for sterilization after the procedure

Answer 30

C
The ultrasound catheter cannot be sterilized, it is disposable. The procedure is performed by the physician while the sonographer assists with the ultrasound machine.

Question 31

If the great saphenous vein is being used to create an situ vein graft,
A. the graft diameter will be greatest at the distal end of the graft
B. all perforator vein must be evaluated for patency because the graft will not function properly with obstructed perforator veins
C. the valves will remain in place and provide little resistance to arterial flow
D. all perforator vein must be marked on the vein mapping so they can be closed

Answer 31

D
You must mark all perforating veins if the GSV will be used as an in situ graft or AV fistula will be created when the graft is arterialized. The valves must be removed with a valvulotome. The graft diameter will be greatest at the proximal end.

Question 32

A patient presents for a follow up exam after radiofrequency ablation of the GSV. What is the purpose of the exam?
A. to assess the valvular motion in the GSV
B. to confirm the contraction of the GSV and absence of thrombus in the deep system
C. to confirm the patency of the GSV and thrombosis of its branches
D. to evaluate thrombus formation in the GSV

Answer 32

B
A follow up exam after radiofrequency ablation of the GSV should be performed 2 weeks after the procedure to confirm contraction/occlusion of the GSV and absence of thrombus in the deep system.

Question 33

Which of the following correctly describes sclerotherapy procedures?
A. physician may inject saline into the superficial veins of the extremity in order to cause increased viscosity and promote the formation of thrombus, which in turn reduces varicosity size
B. physicians may inject saline into the deep veins of the extremity in order to increase viscosity and promote the formation of thrombus, which in turn reduces varicosity size
C. physicians may inject saline into the superficial veins of the extremity in order to improve circulation by thinning the blood, which in turn reduces varicosity size
D. physicians may inject saline into the superficial veins of the extremity in order to cause the vessel to contract and cause fibrosis, which in turn reduces varicosity size

Answer 33

D
Physicians may inject saline into the superficial veins of the extremity in order to cause the vessel to contract and cause fibrosis, which in turn reduces varicosity size.

Question 34

A patient is scheduled for a stab phlebectomy. What is being treated for this patient?
A. carotid stenosis
B. DVT removal
C. pseudoaneurysm
D. varicose veins

Answer 34

D
Stab Phlebectomy
This method removes superficial varicose veins that are not amenable to endovenous ablation. Under local anesthesia, tiny punctures, or microincisions are made. Through these small incisions, phlebectomy hooks extract the varicose veins. The incisions are so small that no stitches are required. Ultrasound guidance can be used to guide the procedure. This procedure is well tolerated by patients and produces excellent cosmetic results.

Question 35

Which of the following is an absolute contraindication to en endovenous ablation?
A. uncooperative patient
B. history of diabetes mellitus
C. daily aspirin use
D. current antibiotic use

Answer 35

A

Question 36

At the start of an endovenous ablation procedure for the great saphenous vein, the catheter is inserted __________ and advanced to a position ____________ before activating the device.
A. into the GSV at the groin, 2cm below the knee
B. into the distal GSV, 2cm distal to the saphenopopliteal junction
C. into the distal GSV, 2 cm distal to the saphenofemoral junction
D. into the GSV at the groin, at the most distal point of reflux

Answer 36

C
At the start of an endovenous ablation procedure for the GSV, the catheter is inserted into the distal vein and advanced to a position 2cm distal to the SFJ before the device is activated. Once activated, the catheter is slowly withdrawn down the leg and out through the puncture site. This should cause fibrosis of the vein in the treated area. The catheter tip must be 2cm or more from the SFJ to prevent damage to the common femoral vein.

Question 37

Endovenous heat-induced thrombosis is a complication of:
A. sclerotherapy
B. radiofrequency ablation
C. microphlebectomy
D. chemical ablation

Answer 37

B
Endovenous heat-induced thrombosis (EHIT) is a complication of radiofrequency ablation. The thrombus that forms in the treated vein can extend into unintended vessels is the deep system. About 7 days after the procedure the patient should return to be evaluated for procedural success and complications like DVT or EHIT.

Question 38

Why is the distance from the most proximal point of the contracted GSV to the saphenofemoral junction measures in a post-ablation exam?
A. to document the lack of thrombus propagation into the deep system
B. to assess the length of the segment that still requires treatment
C. to document that the procedure was unsuccessful
D. all of the above

Answer 38

A
The distance between the SFJ and most proximal point of the fibrosis/thrombosis of the GSV should be measured. If thrombus extends into the deep system, the GSV must be ligated because of the increased risk of embolization.

Question 39

When thrombin is injected in a pseudoaneurysm, the clotting should begin:
A. within 24 hours
B. after 1 minute of manual compression following the injection
C. within 5-10 seconds post-injection
D. within 5-10 minutes post-injection

Answer 39

C
Thrombin administration is performed by injection the clotting agent into a pseudoaneurysm to close the opening and clot the blood that has escaped. Clotting should occur immediately after injection (5-10 seconds). About 20 minutes after the procedure, a follow up exam should be performed to document the pseudoaneurysm is fully thrombosed.

Question 40

If the peak velocity in a TIPS at the portal vein anastomosis is 50cm/s and the mid graft velocity is 25cm/s, what is indicated?
A. there is most likely and occlusion in the graft at the proximal end
B. the mid graft velocity is very low and indicates impending failure of the shunt
C. there is approximately a 50% stenosis at the portal anastomisis
D. the velocities indicate normal flow within the shunt

Answer 40

B

Flow velocity <50cm/s in the TIPS indicates impending failure.

Question 41

A patient is undergoing balloon angioplasty of the left common femoral artery. The physician just completed the first expansion of the balloon and asks you to check the flow with Doppler. Where is the preferred location to evaluate flow?
A. proximal superficial femoral artery
B. popliteal artery
C. dorsalis pedis or posterior tibial artery
D. distal superficial femoral artery

Answer 41

C
The physician is trying to increase flow distal to the obstruction. It is most important to evaluate flow in the most distal areas to evaluate improvement in overall perfusion of the leg.